The effect of balint practice on reducing stress, anxiety and depression levels of psychiatric nurses and improving empathy level

Objective To explore the effect of Balint Group in improving stress, negative mood and empathy of psychiatric nurses. Method In March 2022-March 2023, 150 psychiatric nurses from four hospitals in Lanzhou were selected for the study, randomly grouped into experimental group and control groups (75 per group), the experimental group participated the Balint Group activities biweekly, the control group only attended mental health knowledge lectures. Job stress, negative emotion and empathy of the two groups before and after the intervention were evaluated and compared by using job stressor Scale, coping style Assessment Scale, self-assessment scale for depression, self-assessment Scale for anxiety and Jefferson Empathy Scale. Results After intervention, the job stressor scale and coping style evaluation of nurses in the two groups were significantly decreased, and the experimental group was lower than the control group (P < 0.05). The depression and anxiety of nurses in the two groups were significantly improved, and the experimental group was better than the control group (P < 0.05). The differences in the total score and dimensions of Jefferson Empathy scale in the experimental group after intervention were higher than those in the control group (P < 0.05). Conclusion Balint group activities can effectively relieve the stress, depression and anxiety of psychiatric nurses, and improve the ability of empathy at work.


Introduction
With the increasing pressure in all aspects of society, there are more and more patients with all kinds of mental illness.As an important member of the medical team, psychiatric nurses assume the role of the main caregivers, managers and educators of patients.psychiatric nurses are faced with a special group, often faced with a variety of emergencies, so that they are in a state of high tension for a long time, which is more likely to produce anxiety and depression.A systematic review shows that the prevalence of job burnout of nurses is very high, and there is a certain degree of anxiety, sleep disorders and turnover intention [1].Another study examined the job burnout of psychiatric nurses and found that the sleep quality of psychiatric nurses was positively correlated with psychological distress and job burnout [2].A cross-sectional study in China shows that about 64.0% of nurses have experienced job burnout, and job burnout, hospital level, age, income, night shift and patient-to-nurse ratio are important factors affecting the quality of work and life.It can be seen that job burnout is common among nurses, and job burnout has a negative impact on nurses' quality of work and life [3].Therefore, how to reduce the job burnout of nurses and improve the mental health level of nurses is a hot issue in urgent need of attention and research.
This study intends to use Balint group as an intervention program to study the effect of this intervention program on the improvement of nurses' psychological status.In 1957, Dr. Michael Balint pointed out the details and goals of Balint's team in his book Doctor, patient and Disease [4].Michael Balint is a general practitioner and began holding seminars for general practitioners in 1950.Dr. Balint believes that clinicians need not only professional knowledge, but also the skills to establish good relationships with patients.The Balint group consists of a group of clinicians who meet regularly to discuss the cases they encounter in clinical practice, focusing on the doctor-patient relationship.In the past, Balint's group was mostly conducted among residents, medical students and continuing medical education [5][6][7].In recent years, Balint's team has been gradually applied to the nursing community, and an Italian study shows that group treatment focused on changing personal responses to stressful situations can induce more adaptive strategies enabling caregivers, hematologists, and nurses to help patients better and thereby improve their quality of life [8].A study in China shows that during the COVID-19 pandemic, short-term Balint group activities can improve the communication skills and self-efficacy of front-line nurses to some extent [9].However, previous studies have been conducted in the whole group of nurses, not specific to a certain category of nurses.therefore, This study is based on the Balint group to develop a targeted intervention program.The intervention program was used to relieve the stress, depression and anxiety of psychiatric nurses, improve their empathy ability, and promote the improvement of nurse-patient relationship.

Subjects
This study used two randomized controlled pre-test and post-test studies.Participants from four different hospitals were randomly divided into two groups using a lottery method, with two hospitals serving as the experimental group and two hospitals serving as the control group.75 psychiatric nurses were selected from each group by convenient sampling method.
Inclusion criteria: (1) All were psychiatric nurses in our hospital; (2) Voluntarily participated in this study and signed the informed consent form.
Exclusion criteria: (1) Those who participate in other psychological training activities at the same time; (2) Those who drop out due to time and work problems need to leave their posts for other reasons, such as further study, sick leave and maternity leave.Get rid of nurses who dropped out in the middle of the study; (3) Nurses who practiced and studied; (4) Nurses who were pregnant.

Members of Balint's group
Set up a team: The Balint team consists of a team leader and 14 nurses.The group leader is a nurse who has obtained the qualification certificate of a second-class psychological counselor, has been engaged in psychological counseling for more than ten years and has experience in hosting Balint's group.The group leader is mainly responsible for the pre-training work, but also needs to preside over discussions and organize activities; one deputy team leader is mainly responsible for the selection of each activity case, the distribution and collection of the scale, and the recording of data; two cooperative workers are mainly responsible for the statistics of the scale data.All members have signed informed consent and signed a confidentiality agreement.

Intervention method
The control group only attended the lecture on mental health knowledge held every two weeks in this hospital, each lecture lasted for 60 min, and the lecture was conducted by personnel with deputy senior professional titles and relevant qualifications of the national secondclass psychological qualification certificate.The main content of the lecture is to encourage nurses to look at the problem with a positive attitude, to maintain an optimistic mood, and to discuss and share their experiences with each other after the lecture.The experimental group participated in Batlin group activities, the intervention time was 20 weeks, once every two weeks, a total of 10 times, each time from 60 min to 90 min, with the special study room of the department as the activity place to ensure a quiet and clean environment.
Preliminary training: a Batlin group activity instructor and group leader were assigned by the hospital to train the group members in the early stage of Balint group related knowledge for a total of 3 times.the content of the training is mainly in two aspects: simulation exercises and theoretical knowledge.The contents of the theoretical training include: the source of the Batlin group, the significance of the group activities, objectives, principles, taboos, background, etc., while the contents of the simulation exercises include: the division of labor of the team members, the process of the activities, the method of the case description, the arrangement of seats, and so on.The time of each training is 50 min.
Implementation method: before the formal start of the group activities, the team leader will first assemble the group members, which is conducive to face-to-face communication in the course of the activities.After the official start of the activity, the team leader will make a simple opening statement, including explaining the characteristics and matters needing attention of the Balint group, the purpose, method and matters needing attention of this group activity, and then combining the deputy leader with the on-site situation.select a classic case, select the appropriate case and follow the following process: 1 introduce the case first.The case provider describes the time period, process, cause and location of conflicts and disputes with patients, and expresses their conflicting ideas and perceptions.2 ask relevant questions, after telling the case, the team members need to ask what they do not know about the incident, such as whether there were other people present at that time, when the incident occurred, what time they really thought at that time, and so on.The case provider adds the relevant facts and explains the unclear details in the case.4 at the end of the question, the group leader asked the provider to withdraw from the activity temporarily, and the team members discussed it.5 feedback and summary: the case provider will give feedback and summary, and report their understanding and perception of the event again based on the discussion of the team members.The team leader made a concluding statement on the whole process and thanked all the panelists who participated.

The jefferson scale of empathy-health professionals, JSE-HP
Using the JSE-HP Chinese version score, the scale includes a total of 20 items, divided into three dimensions, the first is opinion picking, a total of 10 items; the second is emotional care, a total of 7 items; the third is for others, a total of 3 items.The scale was scored by Likert's 7-point score, with 1 for complete disagreement, 2 for disagreement, 3 for disagreement, 4 for uncertainty, 5 for a little agreement, 6 for agreement and 7 for complete agreement.The total score is between 17 and 140, and the higher the score, the higher the nurse's empathy ability.Cronbach's alpha coefficient for the Chinese version of the jefferson empathy scale (JSE) was 0.75 overall.

Self-rating anxiety scale, SAS
The Self-rating Anxiety Scale (SAS) compiled by Zung was used to evaluate the depression of the participants, including 20 items, using 4-grade scoring method, 1 occasional or none, 2 very little, 3 quite many, 4 most.The higher the score, the more serious the anxiety.Cronbach's alpha for the SAS in this study was 0.83.

Self-rating depression scale, SDS
The depression score was assessed by Zung Self-Rating Depression Scale (SDS), including 20 items, using 4-grade scoring method, 1 occasional or none, 2 little, 3 quite many, 4 most.The higher the score, the more serious the depression.The standard score is the integer obtained by multiplying the total crude score by 1.25.According to the Chinese norm, the standard score ≥ 53 means depression.Cronbach's alpha for the SDS in this study was 0.9.

Job stressor scale score
The scores of nurses' work stressor scale were compared between the two groups before and after training.The score is 0-10 as low mental stress; 11-15 as moderate mental stress, sometimes feeling stressful but manageable; 16 and above as high mental stress, which needs to reflect on the source of stress and solve it [10].Cronbach's alpha for the Job stressor scale score in this study was 0.9.

Statistical analysis
SPSS26.0 statistical software was used for statistical processing, the measurement data were expressed by mean ± standard deviation, the independent sample t-test was used for comparison between groups, and the counting data were described by frequency and constituent ratio.Chi-square test was used to compare the difference between the two groups.P < 0.05 was regarded as statistically significant.

Participant characteristics
The average age of the test group was 25.17 ± 1.26 years old, including 16 males and 59 females, and 25.16 ± 1.21 years old in the control group, including 19 males and 56 females.There was no significant difference in baseline data between the two groups (P > 0.05).As shown in Table 1.

Comparison of the score of empathy ability between two groups of nurses
There was no significant difference in the scores of emotional ability between the two groups before intervention, but the scores of viewpoint picking, emotional nursing, thinking for others and the total score in the experimental group were higher than those in the control group after intervention (P < 0.05).As shown in Table 2.

Comparison of anxiety score and depression score between the two groups before and after intervention
There was no significant difference in anxiety score and depression score between the two groups before intervention.After intervention, the scores of anxiety and depression in the test group were lower than those in the control group (P < 0.05).As shown in Table 3.

Comparison of nurses' work stressor scale scores between the two groups before and after intervention
Before training, there was no significant difference in the score of job stressor scale between the two groups (P > 0.05), but after training, the score of job stressor   scale of nurses in the two groups was lower than that before training, and that in the experimental group was lower than that in the control group (P < 0.05).The difference was statistically significant (P < 0.05).As shown in Table 4.

Discussion
Psychiatric nurses are mainly faced with patients with mental diseases, such patients are more prone to violence, and nurses are very easy to become victims of violent attacks, long-term maladjustment will affect the physical and mental health of nurses.Studies have shown that the incidence of violence in psychiatric wards is as high as 93% [10].About 10% of nurses are prone to negative emotional experiences such as fear, insomnia, anxiety and depression after experiencing violence [11].In addition, psychiatric nurses will be affected by stigmatization, resulting in low productivity, depression and anger, affecting their work in the hospital environment and the community [12].Due to the particularity of the ward environment of psychiatric hospitals, protective constraints or closed management are usually implemented on patients, and the family members of patients are easy to vent their discontent to nurses, thus increasing the negative mood and stress of psychiatric nurses.The results of Abbas Abdollahi et al. show that the higher the degree of job burnout, the greater the stress [13].When nurses feel too much pressure at work, they are always in a state of nervous tension, which reduces their self-confidence in their work ability and leads to a low sense of achievement.The improvement of stress, negative temperament and empathy in psychiatric nurses as a result of the Balint Group activities is discussed below.

Effect of Balint group intervention on relieving stress of psychiatric nurses
Previous studies have shown that interventions using Balint's group can reduce the stress on nurses caring for patients with advanced cancer [14].This study found that the score of the work stressor scale of psychiatric nurses after participating in Balint group activities was significantly lower than that before intervention, indicating that Balint group activities through the sharing of some representative cases, design layers of interesting, systematic and holistic activity programs to alleviate the occupational fatigue of psychiatric nurses, and then reduce psychological stress.Psychiatric nurses can share and discuss the cases shared by their colleagues or the cases they have experienced, gain experience to overcome their own psychological obstacles, and learn to deal with difficulties at work in a more optimistic and healthy way. it provides a reference basis for reducing the negative emotion caused by external pressure, so as to improve the stress resistance of psychiatric nurses.Therefore, Balint group activities can be used to help psychiatric nurses reduce stress and improve their positive emotions in the face of stress.

Effect of Balint group intervention on reducing anxiety and depression of psychiatric nurses
The results of this study showed that there was no significant difference in the scores of anxiety and depression between the two groups before intervention, but the scores of anxiety and depression in the test group were significantly lower than those in the control group after the intervention.Balint's group can effectively improve the depression and anxiety of nurses, probably because they followed the principles of confidentiality and speaking freely in the course of Balint group activities.It not only provides an open and harmonious environment for nurses, but also ensures the possibility of stable implementation of Balint group activities and ensures the effect of intervention because of its strong maneuverability.On the one hand, in this study, the members of the experimental group are all nursing staff working in the psychiatric department and have similar experiences.through the discussion of the case, we can more fully express their inner feelings in the face of psychiatric negative events, and get more understanding and support when communicating with team members, rather than ridicule and accusation, so as to relieve nurses' anxiety and depression to a certain extent.

Effect of Balint group intervention on improving nursepatient empathy ability of psychiatric nurses
Empathy is a kind of ability that psychiatric nurses must have.Nurses who have empathy skills can communicate better with patients and thus enhance their quality of care [15].However, due to the particularity of psychiatry department and heavy workload, it is difficult to meet the nursing needs of patients and their families, which can easily lead to tense nurse-patient relationship, resulting in lack of empathy and job burnout.At the same time, the lack of empathy ability is also a high risk factor affecting nurses' physical and mental health and nursing quality.How to improve nurses' empathy ability is also a difficult problem for hospital managers.Previous studies have shown that with the Balint group intervention, communication between nurses and patients improved, cooperation between patients and their families increased, and missed tests decreased [9].It has also been found that Balint group training is not an effective intervention to improve well-being and communication skills of psychiatric nurses [16].This study showed that the total scores of experimental group in point of view picking, emotional nursing, consideration for others and total score were higher than those in the control group (P < 0.05).If nurses had strong empathy ability and psychological quality, they could improve patients' compliance and patients' satisfaction.Research by YAZDANKHAHFARDM et al. found that the Balint group could help medical students become more patientcentered by improving their communication skills and empathy and reducing burnout levels [17], This is consistent with the results of this study.Studies have also shown that Balint group training is not an effective intervention to improve well-being and communication skills among psychiatric nurses [16].The inconsistency with the results of this study may be related to the different time spans of the two studies.

Deficiency and prospect
In this study, through the study of on-the-job psychiatric nurses in four third-class hospitals in Lanzhou, Balint group activities can significantly reduce the stress level and anxiety and depression of psychiatric nurses, and significantly improve the empathy ability of nurses.However, the limitation of this study is that the sample size is small, the observation period is only 20 weeks, and the long-term results need to be further followed up and evaluated.At present, the Balint group in China is still in its infancy, and most of the related studies are small sample studies.The scientific, normative and in-depth aspects of the research need to be further improved.At the hospital level, we need to pay attention to the mental health and psychological intervention measures of medical staff, increase humanistic care for staff, take Balint group as a kind of vocational training or continuing education training, and take up as little rest time as possible.
To sum up, the application of Balint group intervention has a good effect on improving nurse-patient relationship and nurses' empathy ability.The results of this paper provide a reference for improving the empathy of psychiatric nurses and reducing the pressure of nursing staff.

Table 1
Comparison of basic data between test group and control group

Table 2
Comparison of empathy ability score between two groups of nurses before and after intervention

Table 3
Comparison of anxiety score and depression score between the two groups before and after intervention

Table 4
Comparison of nurses' work stressor scale scores between the two groups before and after intervention